of patient care, provide information about the underlying causes of errors in the delivery of health care, and to disseminate this information in order to speed the pace of improvement. Composition President Clinton's Advisory Commission on Consumer Protection and Quality in the Health Care Industry completed its work on March 12, 1998. Its final report. entitled "Quality First: Better Health Care for All Americans," recommends the following characteristics of a patient safety organization: Be located in an entity that is credible and respected. Be located in an entity that does not have public or private regulatory responsibilities (i.e., it should not be a licensing, accrediting, or compliance entity). Have the ability to collect and analyze data. Have mechanisms for communicating with a variety of health care entities, facilities, providers, and plans. Be linked with initiatives for conducting interdisciplinary research and demonstrations addressing health care quality improvement. Agency for Healthcare Research and Quality In 2001, the US Congress responded to the IOM recommendation to create a National Center for Patient Safety by allocating $50 million annually for patient safety research to the Agency for Healthcare Research and Quality (AHRQ), the lead federal agency for health care safety. The AHRQ organizes patient safety activities, provides grants to other organizations, serves as a clearinghouse for safety information, and publishes guidelines for evidence-based or "best practices". By 2006, the National Guideline Clearinghouse (NGC) contained more than 1,700 disease-specific diagnosis, management and treatment recommendations, developed from current medical literature. The goal of the NGC is to provide health professionals and institutions, health plans and health care purchasers an accessible mechanism for obtaining objective clinical practice guidelines. Adoption of guidelines has been slowed by physician and hospital concern that practice guidelines threaten physician autonomy and authority, fuel malpractice liability, and allow managed care insurers to curtail patient care expenditures. Under the Secretary of Health and Human Services, the Agency for Healthcare Research and Quality coordinates the Patient Safety Task Force composed of three other agencies with regulatory and data collection responsibilities: the Centers for Disease Control and Prevention (CDC) and its National Electronic Disease Surveillance System, the Centers for Medicare and Medicaid Services (CMS) and state Quality improvement organizations, and the Food and Drug Administration (FDA). The AHRQ, in partnership with data organizations in 37 states, sponsors the Nationwide Inpatient Sample (NIS), a database of the Healthcare Cost and Utilization Project (HCUP). The HCUP is a